McCain May Benefit from Glioblastoma Tx Advances

The announcement that Sen. John McCain (R-Ariz.) has glioblastoma brought to mind the parallels with his longtime colleague and friend, Sen. Edward M. Kennedy (D-Mass.), who also developed a malignant glioma while major healthcare legislation was being considered.

But treatment options for Kennedy were more limited than they are today. New drugs and devices, and especially new diagnostics and surgical procedures, have become available in the years since Kennedy was diagnosed in May 2008. He survived about 15 months after undergoing surgery followed by chemotherapy and radiation treatments.

MedPage Today asked a number of oncologists about how the treatment landscape has changed since Kennedy was treated.

John Sampson, MD, PhD, of the Preston Robert Tisch Brain Tumor Center at Duke University, was a member of the team that operated on Kennedy, told MedPage Today that "new techniques in minimally invasive, image guided surgery and intraoperative MRI have enhanced our ability to take these tumors out with minimal morbidity."

Also highlighting advances in surgical techniques was Walter J. Curran Jr., MD, a radiation oncologist at Emory University: "There have been substantial improvements in surgical approaches, including new methods of detecting tumor anatomy with special illumination techniques and now MR spectroscopy approaches to defining tumor margins for the purpose of radiation planning," he said, citing the work of several other groups.

Similarly, Susan Chang, MD, of the University of California San Francisco, said the recent approval of a fluorescent dye for identifying tumor cells in situ during surgery has been helpful in assuring more complete excision of malignant tissue.

Progress with drug treatments for gliomas got mixed reviews from the experts we contacted. Curran noted the failures of several drugs in extending survival. On the other hand, he said the new immunotherapies such as pembrolizumab (Keytruda) and nivolumab (Opdivo) have changed the landscape, with "initial promising results" in brain cancer.

And Eric Chang, MD, of the University of Southern California, pointed to the "establishment of temozolomide as standard of care for all patients, including advanced age patients such as Sen. McCain," as an important development. He also cited intensity-modulated proton beam therapy as an enhancement to the clinician's arsenal against brain tumors.

Another rapidly changing area is in molecular tumor analysis. Howard Alan Fine, MD, of New York-Presbyterian and Weill Cornell Medicine's Brain Tumor Center in New York City, said this research has "allowed us to prognosticate and to group patients into more homogeneous groups to allow more rationale choices of treatments and for more scientifically rigorous clinical trials."

A treatment not available to Kennedy was approved in 2011: the Optune "tumor treating fields" electrical device. Susan Chang noted that in one recent trial, it appeared to boost 5-year survival from 5% to 13%.

Finally, there are investigational treatments that could be available to McCain. In addition to the approved immunotherapy drugs, other approaches to harnessing the body's immune system to attack brain cancers are in development. So-called CAR T-cell therapies have attracted significant attention for hematologic malignancies, but could also be helpful for gliomas, noted Eric Chang. And a recent study from Duke found that a vaccine against cytomegalovirus had shown benefit for glioma patients in an early trial.

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